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Claim Benefit Specialist

Primary Location: Pittsburgh, PA
Additional Locations: PA-Pittsburgh
The role of the Claims Benefit Specialist is to effectively use knowledge of plans, products, procedures and systems to process a claim under our member’s medical benefits.

Fundamental Components:
As a Claims Benefit Specialist, we strive to achieve first claim satisfaction by processing the claim correctly the first time. This also promotes customer loyalty. By doing the following we can achieve this:
  • Analyzes and approves routine claims that cannot be auto adjudicated.
  • Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
  • Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
  • Routes and triages restricted claims to Senior Claim Benefits Specialist.
  • Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
  • May facilitate training when considered topic subject matter expert.
You would also:
  • Learn about medical procedures.
  • Learn about the different types of insurance benefit plans and understand how they are administered according to the individual plan sponsor’s contract.
  • Derive satisfaction from processing member’s medical claims by resolving the issues which are preventing the claims from automatically adjudicating.
  • Become eligible for bonuses and promotions based on exceptional claim processing skills, job knowledge, and proven performance.

Background Experience:
  • Experience in a production environment is a plus
  • Claim processing experience is a plus.
  • High School or GED equivalent.

Additional Job Information:
Job Characteristics
  • Medical terms are used frequently; terms are taught in training. Medical reference materials are provided.
  • The job involves a consistently high volume of claims.
  • Quality audits are performed.
  • Extensive reference materials are provided to clarify medical procedures, changes in health care providers, claim administration and laws affecting insurance.
  • Excellent organizational skills are a must.
  • Processors need to be able to do several tasks at once, e.g., toggle from one screen to another for information.
  • The position requires excellent attendance and punctuality.
  • Processors are accountable for meeting set quality and production standards.
  • Overtime may be required as business needs are identified.

Functional Skills:
Administration / Operation - Data Entry, Claim - Claim processing - Medical - Medicare

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)


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